Multi-portal surgical systems

ABSTRACT

A multi-portal method for treating a subject&#39;s spine includes distracting adjacent vertebrae using a distraction instrument positioned at a first entrance along the subject to enlarge an intervertebral space between the adjacent vertebrae. An interbody fusion implant can be delivered into the enlarged intervertebral space. The interbody fusion implant can be positioned directly between vertebral bodies of the adjacent vertebrae while endoscopically viewing the interbody fusion implant using an endoscopic instrument. The patient&#39;s spine can be visualized using endoscopic techniques to view, for example, the spine, tissue, instruments and implants before, during, and after implantation, or the like. The visualization can help a physician throughout the surgical procedure to improve patient outcome.

CROSS-REFERENCE TO RELATED APPLICATION

The present application is a continuation of U.S. patent applicationSer. No. 16/565,403, filed Sep. 9, 2019, and entitled “MULTI-PORTALSURGICAL SYSTEMS,” which is incorporated by reference in its entirety.

TECHNICAL FIELD

The present disclosure relates generally to medical systems and, moreparticularly, to systems, devices, and methods for performingmulti-portal surgical procedures.

BACKGROUND

Individuals often suffer from damaged or displaced spinal discs and/orvertebral bodies due to trauma, disease, degenerative defects, or wearover an extended period of time. One result of this displacement ordamage to a spinal disc or vertebral body may be chronic back pain. Acommon procedure for treating damage or disease of the spinal disc orvertebral body may involve partial or complete removal of anintervertebral disc. An implant (commonly referred to as an interbodyspacer) can be inserted into the cavity created where the intervertebraldisc was removed to help maintain height of the spine and/or restorestability to the spine. An interbody spacer may also provide a lordoticcorrection to the curvature of the spine. An example of an interbodyspacer that has been commonly used is a fixed dimension cage, whichtypically is packed with bone and/or bone-growth-inducing materials.Unfortunately, it may be difficult to implant the interbody spacer atthe intended implantation site between vertebral bodies. Additionally,conventional surgical techniques can cause a significant amount oftrauma at or near the implantation site, which can significantlyincrease recovery time and lead to patient discomfort. Accordingly,there is a need for improved surgical systems, visualization techniques,and/or related technologies.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a side view of a multi-portal surgical system in accordancewith an embodiment of the disclosure.

FIG. 2 is a schematic top plan view showing surgical approaches to alumbar spine for performing interbody fusion procedures.

FIG. 3 is an isometric view of the lumbar spine of FIG. 2 .

FIG. 4 is a side view of a tissue removal device positioned betweenadjacent vertebrae and a visualization device positioned to visualize aworking area in accordance with an embodiment of the disclosure.

FIG. 5 is a side view of a distraction instrument with a collapsedexpansion element positioned at an intervertebral space and avisualization device in accordance with an embodiment of the disclosure.

FIG. 6 is a side view of the distraction instrument with the inflatedexpansion element contacting endplates of vertebral bodies in accordancewith an embodiment of the disclosure.

FIG. 7 is a side view of a distraction instrument with an expansionelement in accordance with an embodiment of the disclosure.

FIG. 8 is a side view of an instrument positioned between two vertebraein accordance with an embodiment of the disclosure.

FIGS. 9A, 9B, and 9C are views from an anterior direction of a subject'sspine with an interbody spacer positioned between vertebrae inaccordance with an embodiment of the disclosure.

FIG. 10A is a side view of the interbody spacer in a collapsedconfiguration. FIG. 10B is a side view of the interbody spacer in anexpanded configuration.

FIG. 11 is a flow diagram illustrating a method for performing a spinesurgery in accordance with an embodiment of the disclosure.

FIG. 12 illustrates a system for providing assistance prior to, during,or after surgery according to an embodiment of the disclosure.

FIG. 13 is a plan view of a surgical kit in accordance with anembodiment of the disclosure.

DETAILED DESCRIPTION

The following disclosure describes various embodiments of medicalsystems and devices and associated methods of use. At least someembodiments of a surgical system provide visualization capability. Aseries of instruments can be delivered via portal sites and used toalter tissue (e.g., shape, crush, separate, cut, debulk, break,fracture, or remove tissue), prepare an implantation site, implant adevice, combinations thereof, or the like. Instrument visualization canhelp a physician prevent or limit injury or damage to non-targetedorgans and tissues. In endoscopic-assisted surgeries, devices can beprecisely implanted using minimally-invasive techniques to improveoutcomes and reduce recovery times. Certain details are set forth in thefollowing description and in FIGS. 1-13 to provide a thoroughunderstanding of such embodiments of the disclosure. Other detailsdescribing well-known structures and systems often associated with, forexample, surgical procedures are not set forth in the followingdescription to avoid unnecessarily obscuring the description of variousembodiments of the disclosure.

A. Overview

At least some embodiments are directed to multi-portal surgical systems.The surgical systems can be used to treat patients with damaged ordisplaced spinal discs and/or vertebral bodies. The surgical systems canbe used to implant a fixed or expandable interbody device to space apartvertebral bodies, restore stability of the spine, provide lordoticcorrection, combinations thereof, or the like. In spinal fusionprocedures, interbody devices can be used alone or in combination withbone, bone-growth-inducing materials, fixation devices (e.g., pediclescrew systems, fixation rods, etc.), or the like. The patient's spinecan be visualized using endoscopic techniques to view, for example, thespine (e.g., vertebral spacing, vertebral alignment, etc.), tissue(e.g., damaged or displaced sections of intervertebral cartilage disc,tissue contributing to nerve compression, etc.), instruments andimplants before, during, and after implantation, or the like. Thevisualization can help a physician throughout the surgical procedure toimprove patient outcome.

The surgical system can provide access to the surgical site. Theimplementation site can be prepared by performing a discectomy,interbody preparation procedure, or the like. One or more devices (e.g.,implants, fusion devices, etc.) can be delivered and placed within thepatient. In some embodiments, decompression procedures can be performedto minimize or reduce pressure applied to nerve tissue and can includeremoving tissue contributing to stenosis, tissue pushing against nervetissue, bulging sections of intervertebral cartilage disc, or the like.For example, decompression procedures can be performed to enlarge anepidural space to reduce spinal cord compression.

One surgical method includes positioning a distraction instrumentbetween adjacent vertebrae at a first portal site along the patient toenlarge an intervertebral space. A tissue removal device can be used toclear and prepare the enlarged intervertebral space for implantation. Aninterbody fusion implant can be delivered into the enlargedintervertebral space. The expanding interbody fusion implant isendoscopically viewed using an endoscopic instrument, which ispositioned at a second entrance along the patient. Endoscopic viewingcan be used to evaluate whether the expanded interbody fusion implant isat the desired location, assist in delivering bone graft material, orother steps that promote bone healing and facilitate spinal fusion.Other visualization techniques can be used in combination with theendoscopic viewing. For example, fluoroscopy can be used in combinationwith endoscopic viewing.

In some embodiments, a multi-portal endoscopy-assisted method fortreating a subject includes performing at least a portion of a surgicalprocedure by using a first portal site. At least a portion of thesurgical procedure uses an endoscope positioned via a second portal sitespaced apart from the first portal site. The spacing can be selectedbased on location and accessibility of the treatment site(s), whetheralong the spine or at another location.

In some embodiments, a multi-portal method for treating a subject'sspine includes distracting adjacent vertebrae using a distractioninstrument positioned at a first entrance along the subject to enlargean intervertebral space between the adjacent vertebrae. An interbodyfusion implant is delivered into the enlarged intervertebral space. Theinterbody fusion implant is positioned directly between vertebral bodiesof the adjacent vertebrae while being endoscopically viewed using anendoscopic instrument. The endoscopic instrument can be positioned at asecond entrance along the subject. The positions of the first and secondentrances can be selected based on the accessibility of the implantationsite.

In some yet further embodiments, a multi-portal method for treating aspine of a subject includes positioning a first cannula at a firstportal along the subject. A first vertebral body and a second vertebralbody are distracted using one or more distraction instruments, which canextend through the first cannula. The interbody fusion implant can bemoved, via the first cannula, toward an intervertebral implantation sitebetween the distracted first and second vertebral bodies. At least aportion of the intervertebral implantation site and at least a portionof the interbody fusion implant can be visualized using an endoscopicinstrument positioned at a second portal along the subject.

In some embodiments, a spinal implant delivery instrument includes anelongated body configured to be positioned in a cannula and a distractorassembly. The distractor assembly can be coupled to the elongated bodyand movable from a delivery state to an expanded state to distract firstand second vertebral bodies. In certain embodiments, the distractorassembly in the delivery state is configured for insertion into anintervertebral space between the first and second vertebral bodies andin the expanded state is configured to hold apart distracted first andsecond vertebral bodies while an interbody fusion implant is deliveredinto the intervertebral space.

In further embodiments, a spinal implant delivery instrument includes anelongated body configured to be positioned in a cannula and a distractorassembly coupled to the elongated body. The distractor assembly ismovable from a delivery state to an expanded state to distract first andsecond vertebral bodies. The distractor assembly in the delivery stateis configured for insertion into an intervertebral space and in theexpanded state is configured to hold apart the distracted first andsecond vertebral bodies while an interbody fusion implant is delivered.The interbody fusion implant can be delivered from the distractorassembly and into the intervertebral space. In some embodiments, adriver is detachably couplable to a rotatable connection interface ofthe interbody fusion implant. The driver can move axially to move theinterbody fusion implant directly between the first and second vertebralbodies. The driver is configured to expand the interbody fusion implantfrom a collapsed configuration to a deployed configuration. Thedistractor assembly can include a jaw operable to define a delivery gapthrough which the interbody fusion implant can be delivered.

Embodiments of the present disclosure will be described more fullyhereinafter with reference to the accompanying drawings in which likenumerals represent like elements throughout the several figures, and inwhich example embodiments are shown. Embodiments of the claims may,however, be embodied in many different forms and should not be construedas limited to the embodiments set forth herein. The examples set forthherein are non-limiting examples and are merely examples among otherpossible examples.

B. Multi-Portal Surgical Systems

FIG. 1 is a side view of a spinal surgical system 100 (“system 100”)positioned along a human subject's spine in accordance with anembodiment of the disclosure. The system 100 can include an instrumentassembly 130 and a visualization assembly 160. The instrument assembly130 can be used to perform at least a portion of a surgical procedurewhile the visualization assembly 160 provides visualization. Theinstrument assembly 130 can include an instrument 110 and a cannula 120.Ports can be used to facilitate insertion of the instrument assembly 130and/or visualization assembly 160. For example, the visualizationassembly 160 can be positioned in an endoscope port, and the instrumentassembly 130 can be positioned in an instrument port.

A series of instruments can be delivered through the cannula 120 toperform a surgical procedure. In some procedures, the instrument 110 canbe used to prepare an implantation site by, for example, moving organsor tissue (e.g., moving nerve tissue), removing tissue (e.g., removingthe intervertebral disc 171, tissue contributing to stenosis, etc.),preparing vertebral bodies (e.g., roughening or shaping vertebralendplates), or the like. The instrument 110 can be removed and adistraction instrument can be delivered through the cannula 120. Thedistraction instrument can distract adjacent vertebrae 170, 172, therebyenlarging the intervertebral space. An interbody fusion implant can bedelivered through the cannula 120 and into the enlarged intervertebralspace. In expandable embodiments, the interbody spacer or fusion implantcan be expanded to contact vertebral endplates. During the procedure,the visualization assembly 160 can provide endoscopic viewing ofdelivery paths, organs, tissue (e.g., nerve tissue) implantation sites,interbody fusion devices (e.g., before, during, and/or after delivery),instrument(s), and other areas or features of interest. The position ofthe portal sites for the instrument assembly 130 and the visualizationassembly 160 can be selected based on the procedure to be performed andoptical characteristics (e.g., field of view, zoom capability, etc.) ofthe visualization assembly 160, as discussed in connection with FIG. 4 .

With continued reference to FIG. 1 , the visualization assembly 160 caninclude a visualization device 140 and a cannula 150. The cannula 150can help a physician when switching between visualization devices. Insome embodiments, the visualization assembly 160 can be used without thecannula 150. For example, the visualization device 140 in the form of alow-profile fiber optic endoscope positioned directly through anincision, an endoscopic port, or the like. The visualization device 140can include one or more endoscopes having, without limitation, fiberoptics (e.g., optical fibers), lenses, imaging devices, working lumens,light source controls, or the like for direct viewing or viewing via adisplay 162. In some embodiments, the visualization device 140 caninclude a lumen through which fluid flows to irrigate the surgical site.For example, saline, or another suitable liquid, can be pumped throughthe visualization device 140 to remove tissue (e.g., loose tissue, bonedust, etc.) or other material impairing visualization. The visualizationdevice 140 can illuminate the body cavity and enable high-resolutionvideo visualization. A light source (e.g., a laser, light-emittingdiode, etc.) located near or at the proximal end of the fiber optics canbe used to transmit light to the distal end and provide illuminatinglight. This enables a surgeon to safely navigate into the subject's bodyand to illuminate specific body anatomy to view vertebral spacing,vertebral structures, nerves, bony buildup (e.g., buildup that could beirritating and pressing against nerves contributing to nervecompression), etc. In some embodiments, visualization optics for visionand illumination are included within the distal tip of the visualizationdevice 140. The configuration and functionality of the visualizationdevice 140 can be selected based on the desired field of view, viewingresolution, pan/zoom functionality, or the like.

FIG. 2 is a schematic top plan view along the lumbar spine of a humansubject and illustrates example approaches for performing interbodyfusion procedures suitable for the system 100 of FIG. 1 . FIG. 3 is anisometric view of the lumbar spine of FIG. 2 . Referring to FIGS. 2 and3 , surgical instruments can be delivered via different paths, includingan anterior lumbar interbody fusion (ALIF) path 210, an oblique lumbarinterbody fusion (OLIF) path 220, a lateral or extreme lateral lumbarinterbody fusion (LLIF or XLIF) path 230, a transforaminal lumbarinterbody fusion (TLIF) path 240, and a posterior lumbar interbodyfusion (PLIF) path 250. Example TLIF and PLIF procedures are discussedin connection with FIGS. 4-6 .

With continued reference to FIGS. 2 and 3 , the number and configurationof interbody fusion devices can be selected based on the fusionprocedure to be performed. In one example TLIF procedure, thetransforaminal path 240 may be employed to implant a single smallexpandable or non-expandable interbody spacer at the intervertebralspace. In one example PLIF procedure, two interbody spacers can bedelivered along the posterior path 250 and implanted at theintervertebral space. The two interbody spacers can cooperate to keepthe vertebral bodies at the desired spacing and may be larger than theTLIF spacer. Additionally, multiple interbody spacers can providelordotic correction by providing support at different heights. In oneexample LLIF procedure, a single relatively large interbody spacer canbe delivered along the lateral path 230 and implanted to provideasymmetrical support. In one example ALIF procedure, an asymmetricinterbody spacer can be delivered along the anterior path 210 to providesupport consistent with lordosis at that portion of the spine. Lateralapproaches, transforaminal approaches, and anterior approaches can beused to access the cervical spine, thoracic spine, etc. The number ofinstruments, configurations of instruments, implants, and surgicaltechniques can be selected based on the condition to be treated.

FIG. 4 is a detailed side view of the instrument assembly 130 positionedto perform a TLIF or PLIF procedure in accordance with embodiments ofthe disclosure. The instrument assembly 130 can extend through a port472, and the visualization assembly 160 can extend through a port 474.The illustrated instrument assembly 130 can extend through the subject'sskin 460, through subcutaneous tissue 462, and adjacent to or throughsupraspinal ligament 464. The visualization assembly 160 has a field ofview 213 suitable for viewing the spinal column and can be positionedusing, for example, a transforaminal approach, a posterior approach, ora lateral approach. The illustrated visualization assembly 160 ispositioned to enable viewing an intervertebral disc 430 and a tissueremoval tip 470 of the instrument 110, which is illustrated betweenspinous processes 450, 454 of vertebrae 440, 444, respectively.Fluoroscopy, MR imaging, CT imaging, direct visualization, or othervisualization techniques can be used in addition to or in lieu of theendoscopic viewing.

The tissue removal tip 470 can be advanced in the anterior direction toremove the intervertebral disc 430, or other unwanted tissue, including,without limitation, tissue bulging from disc 430 (or other discs), bone(e.g., lamina, lateral recesses, facets including the inferior facets,etc.), bone spurs (e.g., bone spurs associated with osteoarthritis),tissue of thickened ligaments, spinal tumors, displaced tissue (e.g.,tissue displaced by a spinal injury), or tissue that may cause orcontribute to spinal nerve compression. The instrument 110, as well asother instruments (e.g., rongeurs, debulkers, scrapers, reamers,dilators, etc.), can be used to perform one or more dilation procedures,decompression procedures, discectomies, m icrodiscectom ies,laminotomies, or combinations thereof. In procedures for treatingstenosis, the instrument 110 can be used to remove tissue associatedwith central canal stenosis, lateral recess stenosis, and/or other typesof stenosis. In some decompression procedures, the instrument 110 can bea tissue removal device used to, for example, remove bone, separate theligamentum flavum from one or both vertebrae 440, 444, cut or debulk theligamentum flavum, remove loose tissue, and remove at least a portion ofthe intervertebral disc 430. Each stage can be performed with adifferent instrument. Instruments can be selected to treat, withoutlimitation, spinal nerve compression (e.g., spinal cord compression,spinal nerve root compression, or the like), spinal disc herniation,osteoporosis, stenosis, or other diseases or conditions.

The instrument 110 and the visualization device 140 can be positionedalong different paths. For example, the instrument 110 can be positionedalong a posterior path, whereas the visualization device 140 can bepositioned along a transforaminal or oblique path. The ports 472, 474are positioned at different superior-inferior positions, and the port472 is positioned directly posterior to the treatment site such that alongitudinal axis of the tissue removal device 110 lies in a plane thatis generally parallel to a transverse plane of the subject. Thevisualization device 140 can be, without limitation, an endoscopicinstrument that includes fiber optics 480 suitable to image theligamentum flavum, spinal cord, nerves branching from spinal cord,ligament, vertebrae 440, 444, intervertebral disc 430, or any otherfeatures or anatomical structures of interest while the instrument 110removes tissue (e.g., bone from the vertebrae 440, 444 or tissueintervertebral disc 430).

FIG. 5 is a side view of a distraction instrument with a collapsedexpansion element positioned between two vertebrae after anintervertebral disc has been removed in accordance with an embodiment ofthe disclosure. A distraction instrument 510 is positioned in thecannula 120 and has positioners or stops 530, 534 and an expander ordistractor head 560 (“expander 560”), illustrated in a partiallyexpanded state, configured to push apart the adjacent vertebrae 440,444. Expansion of the expander 560 and the positioners 530, 534 can beviewed endoscopically with the visualization device 140.

The positioners 530, 534 are configured to help position the expander560 insertable into an intervertebral space 570. For example, thepositioner 530 can contact an inferior vertebral notch 550 of thevertebral body 441, and the positioner 534 can contact a superiorvertebral notch 554 of the vertebral body 445. An elongate member 540can be extended or contracted to position the expander 560 at a desiredlocation, while the positioners 530, 534 can remain relativelystationary relative to the vertebral bodies 441, 445. Throughout thisprocess, the visualization device 140 can be used to view thepositioners 530, 534, the elongate member 540, and/or the expander 560.A physician can confirm the condition of expander 560 relative toanatomical features prior, during, and after expansion. This ensuresthat the expander 560 contacts desired regions of the spinal column. Theexpander 560 can be deployed to push against endplates of the adjacentvertebrae 440, 444, thereby enlarging the intervertebral space 570.

The positioners 530, 534 can include spikes, protrusions, or othermovement-inhibiting elements. In some embodiments, anchors orprotrusions can be connected directly to the elongate member 540 and canbe deployed to engage the endplates. The configuration, number, andposition of the positioners can be selected based on the desiredpositioning relative to the spinal column.

The elongate member 540 is connected to the expander 560 and can be arod with one or more lumens through which fluid flows. Fluid (e.g.,saline, gas, or another suitable fluid) can be pumped through theelongate member 540 to inflate the expander 560. For fluoroscopy, thefluid can include a contrast media. The expander 560 can include,without limitation, one or more inflatable members, balloons, mechanicalexpanders, wedging devices, or the like. Arrows indicate one of the manypossible directions of expansion, and the direction of expansion of theexpander 560 is not limited to bidirectional expansion.

The distraction instrument 510 can also deliver an interbody fusionimplant and serve as a driver instrument. The distraction instrument 510can have a shaft connectable to the interbody fusion implant. The shaftcan be rotated to deploy the interbody fusion implant. U.S. Pat. Nos.8,632,594, 9,308,099, 10,105,238 and 10,201,431, which are herebyincorporated by reference and made a part of this application, disclosedriver components that can be incorporated into the distractioninstrument 510.

FIG. 6 is a side view of the distraction instrument 510 with an inflatedexpansion element 560 holding apart the vertebral bodies 441, 445. Thelevel of expansion of expander 560 can be increased or decreased toincrease or decrease, respectively, the pressure applied to theendplates. The expander 560 can include one or more roughened surfaces,spikes, protrusions, or other features capable of roughening, abrading,scraping, or otherwise affecting tissue. In some embodiments, theexpander 560 has a plurality of protruding spikes that can be used toroughen the opposing vertebral endplate surfaces to help limit orsubstantially prevent migration of an implanted device. The expander 560can be collapsed and removed. Another expander can be inserted into thealready-expanded intervertebral space 570 to further distract thevertebrae 440, 444. In this manner, the vertebrae can be sequentiallydistracted in a controlled manner until a desired amount of separationis achieved.

The expander 560 can hold apart the distracted second vertebral bodies441, 445 while an interbody fusion implant is delivered through thedistraction instrument 510 and into the intervertebral space 570. Theinterbody fusion implant can be positioned adjacent to the deployedexpander 560, which can be removed after, for example, deploying theinterbody fusion implant.

The configuration of the instruments can be selected based, at least inpart, on the distance from the portal sites to the treatment site. Thesurgical procedure can be selected based on the steps to be performed.For example, TLIF and PLIF surgery can include a decompression procedurein which tissue along the posterior region of the spine is removed incontrast to an ALIF procedure in which no such decompression procedureis performed. The systems and techniques discussed in connection withFIGS. 4-6 can be modified to perform other types of procedures,including non-spine procedures.

FIG. 7 is a side view of a distraction instrument 700 with an expansionelement in accordance with an embodiment of the disclosure. Theinstrument 700 can include control elements 710, 712, an elongated body720, positioners 730, 740, and an expander assembly 758. The controlelements 710, 712 can be operated to deploy the positioners 730, 740and/or expander assembly 758. For example, a user can manually rotatethe control elements 710, 712 to independently deploy the respectivepositioners 730, 740. For example, the control element 710 can be usedto rotate the positioners 730, 740 away from undeployed positions 732,742 (illustrated in dashed line) and a longitudinal axis 743 of theinstrument 700 and toward the illustrated outwardly deployed positions.

The distraction instrument 700 can be used in a similar manner asdescribed in connection with FIGS. 5 and 6 . For example, the deployedpositioners 730, 740 can rest against adjacent vertebrae. The expanderassembly 758 has an expander or distractor head 760 (“expander 760”)positionable at a desired location suitable for distracting thevertebrae. The expander assembly 758 can include an elongated body 750fluidically connected to a fluid line 751. The expander 760 can bemounted to the distal end of the elongate body 750 such that fluid canbe pumped through the fluid line 751, through the elongated body 750,and into the expander 760.

FIG. 8 is a side view of an instrument 800 positioned to distractadjacent vertebrae in accordance with an embodiment of the disclosure. Adescription of the instruments discussed in connection with FIGS. 4-7applies equally to the instrument 800 unless indicated otherwise.

The instrument 800 can include an access device or cannula 810 and adistraction assembly 828. The cannula 810 can serve as an access devicethrough which the distraction assembly 828 can be delivered. Thedistraction assembly 828 can include positioners 830, 834 configured foratraumatic contact with the spinal column. The positioners 830, 834 canbe inflatable members (e.g., inflatable balloons), mechanically expandedmembers, or other types of elements. The positioners 830, 834 can beconfigured to contact vertebral bodies, transverse processes, spinousprocesses, or the like. The distraction assembly 828 can further includean expandable assembly 848 with an expander 850 and an elongated body852. The illustrated expander 850 is in a collapsed, deflatedconfiguration or state. The expander 850 can be expanded/inflated in amanner similar to the expander 560 discussed in connection with FIGS. 5and 6 . A visualization device can be used to view the expander 850,positioners 830, 834, or other features of the instrument before,during, and/or after the distraction process. In some embodiments, thedistraction assembly 828 can function as a jaw in which the positioners830, 834 can be used to grip or define a delivery gap. Additionally oralternatively, the positioners 830, 834 can be inserted into spaces(e.g., cavities) and then moved apart to expand the spaces.

FIGS. 9A, 9B, and 9C are anterior views from an anterior direction of asubject of an interbody spacer 910 between two vertebrae in accordancewith an embodiment of the disclosure. In FIG. 9B, the interbody spacer910 is in a laterally expanded configuration. In FIG. 9C, the interbodyspacer 910 is in a laterally and vertically expanded configuration. Ingeneral, the interbody spacer 910, in a collapsed configuration, can bedelivered into an intervertebral space. After endoscopically viewing theposition of the interbody fusion implant, the implant can be moved fromthe collapsed configuration (FIGS. 9A and 10A) to an expandedconfiguration (FIGS. 9C and 10B). The expansion (e.g., lateralexpansion, vertical expansion, combinations thereof, etc.) can be viewedusing the endoscopic instrument. The interbody spacer 910 can be,without limitation, an implant, an interbody fusion implant, or thelike. Details of the operation of the interbody spacer 910 are discussedin detail below.

Referring now to FIG. 9A, the intervertebral disc has been removed fromthe intervertebral space 907. The interbody spacer 910 can be deliveredthrough a cannula, such as the cannula 120 of FIGS. 1-7 or the cannula810 of FIG. 8 , to position the collapsed interbody spacer 910 directlybetween endplates 912, 914 of the vertebrae 440, 444, respectively. Theposition of the collapsed interbody spacer 910 can be confirmed viaendoscope viewing. If the interbody spacer 910 is at an undesiredposition, the interbody spacer 910 can be moved to another position.Once again, endoscopic viewing can be used to confirm the final positionof the interbody spacer 910.

FIG. 9B shows the interbody spacer 910 after it has been laterallyexpanded under endoscopic viewing. Advantageously, if the expansionprocess causes unwanted displacement of the interbody spacer 910, theuser can reposition the interbody spacer 910.

FIG. 9C shows the interbody spacer 910 after it has been verticallyexpanded against endplates 912, 914 of the vertebrae 440, 444,respectively. After full expansion, the interbody spacer 910 can belocked to prevent collapse. Optional material can be delivered to theintervertebral space 907 to promote or facilitate fusion. For example,material can be delivered into the intervertebral space 907 via adelivery instrument 920 (FIG. 10A) connected to the interbody spacer910. The material can be bone, bone-growth-inducing materials, cement,or other suitable material. The bone-growth-inducing materials can beconfigured to promote bony arthrodesis. In some procedures, the materialis delivered through passageway of the delivery or driver instrument. Inother procedures, the material can be delivered via a separateinstrument. In some procedures, multiple interbody spacers are implantedat the intervertebral space 907. Details of delivery instruments arediscussed in connection with FIGS. 10A and 10B.

Referring to FIG. 10A, the interbody spacer 910 and delivery instrument920 can be delivered through a port 922, with or without the use of acannula 930. The instrument 920 can include a handle assembly 931, anelongated body 932, and a connecter 934. The handle assembly 931 caninclude a grip 950 and one or more control elements 940 operable tocontrol operation of the interbody spacer 910 and control decouplingfrom the interbody spacer 910. In some embodiments, the control elements940 can include one or more dials, levers, triggers, or other movableelements. The elongated body 932 is connected to the handle 950 andextends to the connecter 934. The elongated body 932 can serve as adriver instrument and can include one or more rods, shafts, or otherelements used to operate the interbody spacer 910. In some embodiments,a driver instrument is inserted through the delivery instrument 920 andinto engagement with the interbody spacer 910. The driver instrument canbe rotated to gradually and controllably deploy the interbody spacer910. The features, configuration, and functionality of the connector 934can be selected based on the configuration of the interbody spacer 910.

FIG. 10B is a side view of the of the expanded interbody spacer 910after the delivery instrument 920 has been separated from a connectionfeature or connection interface 916 (“connection feature 916”) of theinterbody spacer 910. The expanded interbody spacer 910 can be locked inthe expanded configuration. To reposition the interbody spacer 910, thedelivery instrument 920 can be reconnected to the interbody spacer 910and operated to unlock and collapse the interbody spacer 910. Thedelivery instrument 920 can be used to move the collapsed interbodyspacer 910.

The delivery instrument 920 can include one or more distal connectionelements or features for detachably coupling to the interbody spacers.The connection elements can be a polygonal connection (e.g., a hexagonalprotrusion) received by a complementary polygonal recess or feature ofthe interbody spacer 910. Other connections can be used to detachablycouple the delivery instrument 920 to the interbody spacer 910. U.S.Pat. Nos. 8,632,594, 9,308,099, 10,105,238 and 10,201,431, which arehereby incorporated by reference, disclose delivery instruments,interbody spacers, connection features, and methods of operatingdelivery instruments and deploying interbody spacers. The deliveryinstrument 920 can be a delivery instrument and include featuresdisclosed in U.S. Pat. Nos. 8,632,594, 9,308,099, 10,105,238 and10,201,431. Other types of implantable devices and delivery instrumentscan be utilized. The configuration of the implant and correspondingdelivery instruments can be selected based on the procedure to beperformed.

FIG. 11 is a flow diagram illustrating a method for treating a subjectin accordance with an embodiment of the disclosure. In block 1002,incisions can be made in the subject's tissue to create first and secondportal sites (i.e., entrances). In some embodiments, the first andsecond entrances can be positioned on the same side of the subject'smidsagittal plane. In other embodiments, the first and second entrancescan be positioned on opposite sides of the subject's midsagittal plane.In yet other embodiments, the incisions can be made along the subject'smidsagittal plane.

Ports can be installed in each of the entrances. The sizes of the portscan be selected based on the size of the incision and characteristics ofthe tissue at the port site. For example, a tubular body of the port canbe sufficiently long to extend through the subject's skin, fascia, andmuscle. An access opening of the port can be sufficiently large to allowinstruments to be inserted into and through the ports, which can preventor inhibit tearing of tissue. Instruments can be delivered through theincisions into the patient without utilizing ports. Such instruments canhave relatively small diameters to limit or inhibit tearing of thetissue around the incision. In some procedures, ports can be installedin some incisions and instruments can be installed in other incisionswithout ports. A physician can determine whether to install ports basedon the instruments to be utilized and the position of the incisions.

In block 1004, a distraction instrument can be positioned at the firstportal site by inserting the distraction instrument through, forexample, an installed port. In some procedures, a cannula can bepositioned in the port and the distraction instrument can be deliveredthrough the lumen of the cannula. In other embodiments, the distractioninstrument can be inserted directly into the port without utilizing thecannula. Utilization of distraction instruments and cannulas arediscussed in connection with FIGS. 5-8 .

In block 1006, a visualization device can be positioned at a secondportal site by delivering the visualization device through a port. Thevisualization device can be installed with or without use of thecannula. Utilization of a cannula and a port are discussed in connectionwith FIGS. 1-7 . In some embodiments, the visualization device can be alow-profile fiber optic visualization system deliverable through aportal site in the form of a small incision. In these procedures, acannula may not be used since the visualization device has a smalldiameter. The visualization device can be kept at the same portal sitethroughout most of the surgical procedure period in which the spine isaltered. For example, the visualization device can be positioned at asingle portal site for at least 80% or 90% of the surgical period inwhich instruments are positioned in the subject. The visualizationdevice can be positioned within the subject such that an interbodyfusion device is capable of being implanted without removing theendoscope from the subject. This can reduce the overall surgery time.

A steerable visualization device can be used to facilitate navigationaround anatomical features. The steerable visualization device caninclude a fiberoptic scope, or a flexible or rigid instrument with oneor more illumination elements (e.g., fiber-optics for illumination) orimaging elements (e.g., charge-coupled devices for imaging) suitable forvisualizing the interior of otherwise inaccessible sites. In someembodiments, the visualization device can be rod-lens endoscopes with anouter diameter equal to or smaller than about 2 mm, 3 mm, 4 mm, 5 mm, 6mm, 8 mm, or 10 mm; and a length equal to or shorter than about 15 cm,20 cm, 30 cm, or 40 cm. The device can also have connectors (e.g.,electrical connectors, fluidic connectors, etc.), access ports (e.g.,access ports connected to lumens (e.g., lumens through which instrumentscan pass)), or the like. In embodiments with an angled lens, thevisualization instrument can have approximately 15 degree, 30 degree, or45 degree lens angles, which are toward a light source. In other angledlens embodiments, the visualization instrument can have an approximately15 degree, 30 degree, or 45 degree lens angled away from a light source.The angle of the lens can be selected based on the area to be viewed. Insome posterior or lateral spinal procedures, a 0 degree lens can providea wide-angle view suitable for viewing nerve roots, the spinal cord, andintervertebral space. A 30 or 45 degree lens endoscope angled toward thelight source can be used to provide an angled view toward, for example,the midsagittal plane to view, for example, the spinous processes,spinal cord, central regions of the intervertebral space. A 30 or 45degree lens endoscope angled away from the light source can be used toprovide an angled view toward the lateral features or the spine, such asnerve roots at the neural foramen, side regions of the intervertebralspace, or the like.

In some procedures, multiple visualization instruments are utilized. Inone procedure, multiple visualization instruments are positioned withinthe same port, which is large enough to allow relative movement betweenthe endoscopic instruments. In other procedures, endoscopic instrumentsare positioned in spaced apart ports. To provide bilateral viewing, afirst port and first endoscopic instrument can be positioned on one sideof the midsagittal plane of the subject, and the other port andendoscopic instrument can be positioned on the other side of themidsagittal plane. Multiple visualization instruments used in a singleprocedure can have different viewing characteristics.

The images of the subject's spine can be used to determine implantationinformation about the interbody fusion implant. Implantation informationcan include, without limitation, a recommended interbody fusion implant,expansion setting for the interbody fusion implant, and/or recommendedimplantation position for the interbody fusion implant. The user can bepresented information for viewing based on the analysis of the imagedata, including information for repositioning the interbody fusionimplant or information for collapsing the interbody fusion implant. Inblock 1008, tissue from the intervertebral space can be removed with atissue removal device positioned at the first entrance. In block 1010,adjacent vertebrae can be distracted using the distraction instrument toenlarge the intervertebral space between the adjacent vertebrae. Inblock 1012, an interbody spacer, such as an interbody fusion implant,can be delivered to the enlarged intervertebral space. The interbodyfusion implant can be delivered in a collapsed configuration through alumen of the distraction instrument. In block 1014, the interbody fusionimplant can be expanded laterally and vertically while a driverinstrument is positioned within the distraction instrument positioned atthe first entrance and while being endoscopically viewed in block 1016.The lateral and vertical expansion of the interbody fusion implant canbe sequential. For example, after the interbody fusion implant ishorizontally expanded, the interbody fusion implant can be verticallyexpanded to provide disc height restoration.

In block 1016, image data can be obtained by an endoscopic instrument.The image data can be video, still images, or other image data. Imagedata can be obtained before, during, and/or after expansion and analyzedwith endoscopic visualization to confirm the position of the expandedinterbody fusion implant to improve efficacy of surgeries by allowingthe physician to visually assess the procedure. For example, a firstimage of an implantation site can be obtained by the endoscopicinstrument. A second image of the implantation site can be obtainedusing the endoscopic instrument after delivery of the interbody fusionimplant. Image data can be analyzed to determine whether the expandedinterbody fusion implant is located at a deployment position based on aposition of the expanded interbody fusion implant shown in the secondimage.

In some embodiments, the first image and the second image can becompared to determine the position of the expanded interbody fusionimplant. If the interbody fusion implant is mispositioned, the user canbe notified of the mispositioning. The notification can be via anaudible alert, visual alert (e.g., an alert displayed on the display 162at FIG. 1 ), or by other suitable notification means. In block 1018, thedriver instrument can be separated from a locked expanded interbodyfusion implant, as discussed in connection with FIG. 10B. The implantedinterbody fusion implant can be visualized to confirm proper positioningand deployment of the implant. Visualization can be used if additionalprocedures are performed. Additional procedures may include, withoutlimitation, delivering bone, growth-promoting materials, or the like tothe intervertebral space. Visualization can also be used to view otherprocedures, such as fixation procedures involving pedicle screws,interspinous spacers, or the like.

The method of FIG. 11 can be performed using various systems disclosedherein. Additional instruments and steps can be performed as needed toprovide treatment flexibility. For example, decompression procedures canbe performed before or after distracting the adjacent vertebrae at block1010. Visualization can be used during the decompression procedure tovisually identify targeted tissue, as well as ensuring that non-targetedtissue (e.g., nerve tissue) is not traumatized. Although the method isdiscussed in connection with implanting an interbody fusion implant, themethod can be performed to deploy and implant other devices. Forexample, the method can be used to implant an articulatingintervertebral disc. Moreover, the multi-portal systems can be used toimplant rigid or fixed interbody fusion devices. The acts and steps inthe method of FIG. 11 can be modified based on the features of theimplant to perform, for example, an oblique lumbar interbody fusionprocedure, a lateral lumbar interbody fusion procedure, a posteriorlumbar interbody fusion procedure, a transforaminal lumbar interbodyfusion procedure, or an anterior lumbar interbody fusion procedure.

FIG. 12 illustrates a system 1110 for providing surgical assistanceaccording to an embodiment of the disclosure. The system 1110 canimprove surgeries by displaying image data, analyzing image data,suggesting steps in a surgical procedure, analyzing implants, or thelike. The system 1110 can comprise hardware components that improvesurgeries using, for example, a surgical assistance system 1164. Invarious implementations, the surgical assistance system 1164 can storepatient information, obtain image data, analyze information/data toobtain results, and use the results to provide feedback to a user. Thesurgical assistance system 1164 can analyze still images or video frominput devices 1120 to suggested implants for a procedure. For example,the surgical assistance system 1164 can recommend the number, size, andconfiguration of implants and surgical procedure. Based on therecommendations, the surgical assistance system 1164 can further suggestsurgical instruments, a surgical plan, and other information. Thesurgical plan can include (1) surgical steps, (2) number, size, and/orposition of ports, and/or (3) surgical approaches. For example, thesurgical assistance system 1164 can annotate an image (e.g., an X-rayimage, still image, video, etc.) with suggested insertion points alongthe subject's skin, surgical procedures (e.g., PLIF, ALIF, LLIF, etc.),access paths, etc. During a procedure, the surgical assistance system1164 can provide warnings or other feedback to surgeons.

System 1110 can include one or more input devices 1120 that provideinput to the processor(s) 1145 (e.g., CPU(s), GPU(s), HPU(s), etc.),notifying it of actions. The actions can be mediated by a hardwarecontroller that interprets the signals received from the input deviceand communicates the information to the processors 1145 using acommunication protocol. The processors 1145 can be used to analyze data,such as image data, to determine whether the expanded interbody fusionimplant is located at a deployment position based on a position of theexpanded interbody fusion implant shown in an acquired image.

Input devices 1120 can include, for example, visualization devices, suchas the visualization device 140 discussed in connection with FIGS. 1-6 ,endoscopic instruments, imaging devices (e.g., cameras), CRT machines,X-ray machines, or the like. The visualization, in some surgicalembodiments, enables surgeons to visually see and verify the vertebralbodies, vertebral spacing, damaged/displaced tissue, intervertebraldiscs (including bulging portions), presence of unwanted cartilage(e.g., cartilage buildup), bone, or tissue that is causing nerve rootcompression and damage to normal body functions. This information on theunwanted material can be documented and recorded by saving image datainto a computer database and printing color images (e.g., pictures)immediately for reference and recording. The physician can use theinformation to develop at least a portion of a surgical plan.

Additionally or alternatively, the input devices 1120 can include amouse, a keyboard, a touchscreen, an infrared sensor, a touchpad, awearable input device, a camera- or image-based input device, amicrophone, or other user input devices. For example, a mouse can beused to select or manipulate image data captured by visualizationdevices. A keyboard can be used to annotate image data. The number andconfiguration of the input devices can be selected based on thephysician.

Processors 1145 can be a single processing unit or multiple processingunits in a device or distributed across multiple devices. Processors1145 can be coupled to other hardware devices, for example, with the useof a bus, such as a PCI bus or SCSI bus. The processors 1145 cancommunicate with a hardware controller for devices, such as for adisplay 1130. The display 1130 can be used to display image data. Forexample, the display 1130 can correspond to the display 162 in FIG. 1 ,which can be connected to one or more visualization devices via a wiredor wireless connection (FIG. 1 shows a wired connection). The display1130 can present information for viewing by a user. The presentedinformation can include suggested implant information, suggestedsurgical instruments, information for implanting devices, informationfor repositioning the interbody fusion implant, information forcollapsing the interbody fusion implant, or the like. The informationcan be overlaid on or inserted into images or video. In someembodiments, the information can be annotations.

The display 1130 can provide graphical and textual visual feedback to auser. In some implementations, the display 1130 includes the inputdevice as part of the display, such as when the input device is atouchscreen or is equipped with an eye direction monitoring system. Insome implementations, the display is separate from the input device.Examples of display devices are: an LCD display screen, a light-emittingdiode (LED) display screen, a projected, holographic, or augmentedreality display (such as a heads-up display device or a head-mounteddevice), and so on. The display 1130 can provide high definitionvisualization.

Other I/O devices 1140 can also be coupled to the processor, such as anetwork card, video card, audio card, USB, firewire or other externaldevice, camera, printer, speakers, CD-ROM drive, DVD drive, disk drive,or Blu-Ray device. Other I/O 1140 can also include input ports forinformation from directly connected medical equipment such as MRImachines, X-Ray machines, etc. Other I/O 1140 can further include inputports for receiving data from these types of machine from other sources,such as across a network or from previously captured data, e.g. storedin a database.

The system 1110 can also include a communication device capable ofcommunicating wirelessly or wire-based with a network node. Thecommunication device can communicate with another device or a serverthrough a network using, for example, TCP/IP protocols. The system 1110can utilize the communication device to distribute operations acrossmultiple network devices.

The processors 1145 can have access to a memory 1150 in a device ordistributed across multiple devices. A memory includes one or more ofvarious hardware devices for volatile and non-volatile storage, and caninclude both read-only and writable memory. For example, a memory cancomprise random access memory (RAM), various caches, CPU registers,read-only memory (ROM), and writable non-volatile memory, such as flashmemory, hard drives, floppy disks, CDs, DVDs, magnetic storage devices,tape drives, device buffers, and so forth. A memory is not a propagatingsignal divorced from underlying hardware; a memory is thusnon-transitory. Memory 1150 can include program memory 1160 that storesprograms and software, such as an operating system 1162, surgicalassistance system 1164, and other application programs 1166. Memory 1150can also include data memory 1170 that can include, e.g., implantationsite information (e.g., level information, implant deploymentinformation, etc.), surgical plan data, user options or preferences,image data, etc., which can be provided to the program memory 1160 orany element of the system 1110.

Some implementations can be operational with numerous other computingsystems, environments or configurations. Examples of computing systems,environments, and/or configurations that may be suitable for use withthe technology include, but are not limited to, personal computers,server computers, handheld or laptop devices, cellular telephones,wearable electronics, tablet devices, multiprocessor systems,microprocessor-based systems, programmable consumer electronics, networkPCs, minicomputers, mainframe computers, distributed computingenvironments that include any of the above systems or devices, or thelike.

The foregoing detailed description has set forth various embodiments ofthe devices and/or processes via the use of block diagrams, flowcharts,and/or examples. Insofar as such block diagrams, flowcharts, and/orexamples contain one or more functions and/or operations, it will beunderstood by those within the art that each function and/or operationwithin such block diagrams, flowcharts, or examples can be implemented,individually and/or collectively, by a wide range of hardware, software,firmware, or virtually any combination thereof. In one embodiment,several portions of the subject matter described herein may beimplemented via Application Specific Integrated Circuits (ASICs), FieldProgrammable Gate Arrays (FPGAs), digital signal processors (DSPs), orother integrated formats. However, those skilled in the art willrecognize that some aspects of the embodiments disclosed herein, inwhole or in part, can be equivalently implemented in integratedcircuits, as one or more computer programs running on one or morecomputers (e.g., as one or more programs running on one or more computersystems), as one or more programs running on one or more processors(e.g., as one or more programs running on one or more microprocessors),as firmware, or as virtually any combination thereof, and that designingthe circuitry and/or writing the code for the software and or firmwarewould be well within the skill of one skilled in the art in light ofthis disclosure. In addition, those skilled in the art will appreciatethat the mechanisms of the subject matter described herein are capableof being distributed as a program product in a variety of forms, andthat an illustrative embodiment of the subject matter described hereinapplies regardless of the particular type of signal bearing medium usedto actually carry out the distribution. Examples of a signal bearingmedium include, but are not limited to, the following: a recordable typemedium such as a floppy disc, a hard disk drive, a CD, a DVD, a digitaltape, a computer memory, etc.; and a transmission type medium such as adigital and/or an analog communication medium (e.g., a fiber opticcable, a waveguide, a wired communications link, a wirelesscommunication link, etc.).

C. Surgical Kits

FIG. 13 is a top plan view of a surgical kit 1200 that includescomponents discussed in connection with FIGS. 1-11 . The kit can includecannulas 120, 150 and a set 1210 of ports. A physician can selectappropriate ports based on locations of portal sites and instruments tobe utilized. In the illustrative embodiment, the set 1210 includes fourports. A higher or lower number of ports can be provided and can be ofthe same or different sizes. The kit 1200 can include a connector (e.g.,a rigid connector) to couple together cannulas (e.g., cannulas 120,150). The cannulas can be coupled together before expanding theinterbody fusion device at an intervertebral implantation site.

The kit 1200 can further include a plurality of decompressioninstruments. In the illustrated embodiment, the kit 1200 includes adebulking instrument 1220 and a reamer 1222. If the decompressioninstruments are utilized, a physician can select the port 1230 with alarge opening 1232. The kit 1200 can also include scalpels, dilators,rongeurs, or other surgical instruments. The kit 1200 can include thevisualization device 140, the distraction instrument 510, the deliveryor deployment instrument 920, and implantable devices 1238. Theconfiguration and components for the kit can be selected based upon theprocedure to be performed. Moreover, one or more of the kit's componentscan be disposable and can be made from metal, polymer, ceramic,composite, or other biocompatible and sterilizable material.

The above detailed descriptions of embodiments of the technology are notintended to be exhaustive or to limit the technology to the precise formdisclosed above. Although specific embodiments of, and examples for, thetechnology are described above for illustrative purposes, variousequivalent modifications are possible within the scope of thetechnology, as those skilled in the relevant art will recognize. Forexample, while steps are presented in a given order, alternativeembodiments may perform steps in a different order. Features fromvarious systems, methods, and instruments can be combined with featuresdisclosed in U.S. Pat. Nos. 8,632,594, 9,308,099, 10,105,238 and10,201,431, which are hereby incorporated by reference and made a partof this application. Variations of the implants are contemplated. Forexample, the interbody spacer 910 (FIGS. 9A-9C) may be provided withdifferent overall heights covering a range of intervertebral discheights. In other examples, the interbody spacer 910 may be providedwith different lordotic and/or kyphotic angles. In still other examples,the interbody spacer 910 may be provided with other patterns orfeatures, such as spikes, protrusions, or the like on the bonecontacting surfaces that provide stability and/or resistance to shiftingpositions. The implant may be made from metal, polymer, ceramic,composite, or other biocompatible and sterilizable material. Differentmaterials may be combined in what is described herein as a single part.

Systems, components, and instruments disclosed herein can be disposableor reusable. For example, the ports, instruments, or cannulas can bedisposable to prevent cross-contamination. As used herein, the term“disposable” when applied to a system or component (or combination ofcomponents), such as an instrument, a tool, or a distal tip or a head,is a broad term and generally means, without limitation, that the systemor component in question is used a finite number of times and is thendiscarded. Some disposable components are used only once and are thendiscarded. In other embodiments, the components and instruments arenon-disposable and can be used any number of times. In some kits, all ofthe components can be disposable to prevent cross-contamination. In someother kits, components (e.g., all or some of the components) can bereusable.

Where the context permits, singular or plural terms may also include theplural or singular term, respectively. Moreover, unless the word ‘or’ isexpressly limited to mean only a single item exclusive from the otheritems in reference to a list of two or more items, then the use of ‘or’in such a list is to be interpreted as including (a) any single item inthe list, (b) all of the items in the list, or (c) any combination ofthe items in the list. Additionally, the term “comprising” is usedthroughout to mean including at least the recited feature(s) such thatany greater number of the same feature and/or additional types of otherfeatures are not precluded. It will also be appreciated that specificembodiments have been described herein for purposes of illustration, butthat various modifications may be made without deviating from thetechnology. Further, while advantages associated with certainembodiments of the technology have been described in the context ofthose embodiments, other embodiments may also exhibit such advantages,and not all embodiments need necessarily exhibit such advantages to fallwithin the scope of the present technology. Accordingly, the disclosureand associated technology can encompass other embodiments not expresslyshown or described herein.

1-49. (canceled)
 50. A multi-portal surgical method comprising:positioning an instrument cannula at a first entrance along a subject;positioning a visualization cannula at a second entrance along thesubject, wherein the first and second entrances are positioned on oneside of a midsagittal plane of the subject and spaced apart from oneanother; removing tissue from a working region inside the subject usingat least one instrument positioned in the instrument cannula; andendoscopically viewing the at least one instrument removing the tissueusing an endoscopic viewing instrument positioned in the visualizationcannula and spaced apart from the subject's spine such that other tissueat the working region is within a field of view of the endoscopicviewing instrument.
 51. The multi-portal surgical method of claim 50,further comprising: using the at least one instrument to remove at leasta portion of a facet and surrounding tissue of the subject to define atransforaminal path to an intervertebral space between two adjacentvertebrae; and delivering an interbody spacer along the transforaminalpath and into the intervertebral space.
 52. The multi-portal surgicalmethod of claim 51, further comprising endoscopically viewing, using theendoscopic viewing instrument, removal of the portion of the facet andthe surrounding tissue and delivery of the interbody spacer into theintervertebral space.
 53. The multi-portal surgical method of claim 51,further comprising: positioning the endoscopic viewing instrument toview non-targeted tissue at or near the working region; and removing thetissue from the working region while viewing and leaving thenon-targeted tissue intact.
 54. The multi-portal surgical method ofclaim 50, further comprising endoscopically viewing, using theendoscopic viewing instrument, nerve tissue while the tissue is beingremoved to avoid removal of the nerve tissue.
 55. The multi-portalsurgical method of claim 50, further comprising: viewing, usingfluoroscopy, nerve compression along the subject's spine; and viewing,using the endoscopic viewing instrument, reduction of the nervecompression attributable to the tissue removal.
 56. The multi-portalsurgical method of claim 50, further comprising pumping liquid throughthe endoscopic viewing instrument such that the liquid carries thetissue removed from the working region out of the subject.
 57. Themulti-portal surgical method of claim 50, wherein the at least oneinstrument includes one or more of: a rongeur, a reamer, a debulker, ora scaper.
 58. The multi-portal surgical method of claim 50, furthercomprising performing, under endoscopic viewing of the endoscopicviewing instrument, at least one of: a decompression procedure, adiscectomy, a microdiscectomy, or a laminotomy.
 59. The multi-portalsurgical method of claim 50, further comprising imaging the workingregion using fluoroscopy while the at least one instrument and theendoscopic viewing instrument are positioned in the subject.
 60. Themulti-portal surgical method of claim 50, further comprising performingimaging-guided implantation by imaging, using fluoroscopy, an implantand the working region.
 61. A multi-portal method for treating asubject, comprising: positioning an endoscopic instrument at avisualization entrance along the subject; distracting adjacent vertebralendplates using a distraction instrument to enlarge an intervertebralspace, wherein the distraction instrument is positioned at an instrumententrance located along the subject and spaced apart from thevisualization entrance; moving an implant at least partially into theenlarged intervertebral space; and endoscopically viewing the implantusing the endoscopic instrument, which is spaced apart from theintervertebral space, to view the implant, the adjacent vertebralendplates, and nerve tissue proximate to the intervertebral space. 62.The multi-portal method of claim 61, further comprising usingfluoroscopy to view: the implant prior to releasing the implant from adelivery instrument, the implant during expansion of the implant in thesubject, and the implant after completing expansion of the implant. 63.The multi-portal method of claim 61, further comprising endoscopicallyviewing, using the endoscopic instrument, one or more nerve roots andopposing side regions of the intervertebral space.
 64. The multi-portalmethod of claim 61, further comprising endoscopically viewing, using theendoscopic instrument, one or more nerve roots and opposing side regionsof the intervertebral space.
 65. A kit comprising: an instrument cannulaconfigured to be positioned at a first entrance along a subject;visualization cannula at a second entrance along the subject, whereinthe first and second entrances are positioned on one side of amidsagittal plane of the subject and spaced apart from one another; andinstruments configured to remove tissue from a working area inside thesubject when positioned in the instrument cannula and beingendoscopically viewed by an endoscopic viewing instrument positioned inthe visualization cannula, which is spaced apart from the subject'sspine to view other tissue at the working area, wherein the instrumentsinclude a rongeur, a reamer, a debulker, and/or a scraper.
 66. The kitof claim 65, wherein each of the instruments is longer than theinstrument cannula.
 67. The kit of claim 65, wherein the instruments areconfigured to be sequentially positioned in the instrument cannula.